Inguinal Hernias

Question 1

What are the risk factors for an inguinal hernia in an adult?

Answer 1

• male sex
• obesity
• constipation
• chronic cough
• heavy lifting

Question 2

What are the risk factors for inguinal hernias in infants?

Answer 2

• prematurity
• male sex

Question 3

Do inguinal hernias occur gradually or suddenly?

Answer 3

In older children and adults they usually develop gradually

Can occur suddenly with an episode of heavy lifting

Question 4

How might an inguinal hernia present?

Answer 4

1. Swelling in the groin
   
   • may appear with lifting
   • may be accompanied by sudden pain
2. An increase (or an impulse) may be palpable on coughing
3. If a lump is present, it may be reducible

Question 5

Briefly discuss the evolution of an inguinal hernia and how it would change clinical presentation

Answer 5

1. First appearance
   
   • usually easily reducible when patient reclines
   • but if large it may require manual replacement
2. With time…
   
   • hernia enlarges and becomes harder to replace
   • (due to fibrous adhesions forming)
3. When it can no longer be reduced… it is irreducible or incarcerated
   
   • can occur at any time
   • strangulation can also occur at any time
     
     • eventually leads to infarction and usually to bowel obstruction

Question 6

What are the types of inguinal hernias?

Answer 6

Indirect

and

Direct

Question 7

Where is the deep (internal) ring situated?

Answer 7

above the midpoint of the inguinal ligament

Inguinal Ligament is lateral to the epigastric vessels.

Midpoint of the inguinal ligament is halfway between the pubic tubercle and the anterior superior iliac spine

Question 8

Where is the superficial (external) ring found?

Answer 8

superficial ring lies just superior to the pubic tubercle

Question 9

What is contained in the inguinal canal?

Answer 9

• spermatic cord
  
  • neurovascular and reproductive structures that supply and drain the testes
• round ligament (females only)
• ilioinguinal nerve
  
  • contributes sensory innervation of genitalia
  • nerve most at risk during repair
• genital branch of the genitofemoral nerve
  *

Question 10

What three vessels are contained in the spermatic cord?

Answer 10

• testicular artery
• cremasteric artery
• artery to the vas

Question 11

What three nerves are contained in the spermatic cord?

Answer 11

• genital branch of genitofemoral
• autonomic supply to the testicle
• ilioinguinal nerve

Question 12

What three structures are contained in the spermatic cord?

Answer 12

• vas
• pampiniform venous plexus
• testicular lymphatics

Question 13

What type of inguinal hernias are more common?

Answer 13

Indirect

Question 14

List the boundaries of the inguinal canal

Answer 14

1. Anterior wall
2. Poserior wall
3. Roof
4. Floor

Plus 2 openings: superficial and deep rings

Question 15

What makes up the anterior wall of the inguinal canal?

Answer 15

aponeurosis of the external oblique, reinforced by the internal oblique muscle laterally

Question 16

What makes up the posterior wall of the inguinal canal?

Answer 16

transversalis fascia

Question 17

What makes up the floor of the inguinal canal?

Answer 17

the inguinal ligament, thickened medially by the lacunar ligament

Question 18

Describe what happens in an indirect hernia

Answer 18

1. Failure of the processus vaginalis to regress
   
   • i.e. failuer of the inguinal canal to close properly after passage of the testis in utero or during neonatal period
2. There’s a protrusion through internal inguinal ring which passes along the inguinal canal, through the abdominal wall, running laterally to the inferior epigastric vessels

Question 19

Describe what happens in a direct hernia

Answer 19

the hernia protrude directly through a weakness in the posterior wall of the inguinal canal, running medially to the inferior epigastric vessels

Question 20

Where is an indirect hernia in relation to the epigastric vessels?

Answer 20

lateral

Question 21

Where is a direct hernia in relation to the epigastric vessels?

Answer 21

Medial

Question 22

What are the differenital diagnoses for inguinal hernia?

Answer 22

• Femoral hernia
  
  • either irreducible or reduces only slowly with pressure
• Hydrocele
• Spermatic cord hydrocele
• Lymph node swelling
• Abscess
• Saphena varix
• Varicocele
• Bleeding
• Undescended testis

Question 23

What investigations would you do if you suspected an inguinal hernia?

Answer 23

Ultrasound is the least invasive method, if there is doubt

Question 24

What surgical technique is used for open hernia repair?

Answer 24

Lichtenstein technique

(a piece of open-weave polypropylene mesh is used to repair adn reinforce the abdominal wall. Gives earlier mobility and has a very low recurrence rate)

Question 25

How should bilateral hernias be repaired?

Answer 25

Laparoscopically

• less postoperative pain
• full recovery is better
• return to work is fast

Question 26

What are the post-operative complications for inguinal hernia repair?

Answer 26

• bleeding
• infection
• pain
  
  • acute
  • chronic
• recurrence
• cardiovascular and pulmonary complications
• neurovascular injury

Question 27

What do you need to know about Hesselbach’s triangle?

Question 28

What makes up the borders of Hesselbach’s triangle?

Answer 28

• inguinal ligament inferiorly
• inferior epigastric artery laterally
• lateral border of the rectus muscle medially